678

Medatrax Pt. Reference Number

Age:

Date of Birth:

Gender: Male Female Comment:

Ethnicity: Latino

Chief Complaint (CC)

In patient’s own words. Identity and reliability of informant if patient is not informant.

History of Present Illness (HPI)

**GYN Focus**

Must include Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, and Severity (OLDCARTS). Include pertinent positives from the review of systems as they relate to the HPI.

OB/GYN history

Gravida/Para. Last menstrual period. Last PAP w/ results. Last Mammogram w/ results. History of STD, last sexual partner, sexual history, birth control hx

Past Medical History (PMH)

In chronological order: Current/Past medical problems with date of onset

Past Surgical History (PSH)

In chronological order: Surgeries and Procedures with date performed and outcome

Immunization status

Age specific immunizations, list and describe any history of reactions

Medications

**birth control**

Current medications: include medication name, dose, route, frequency, duration, and reason for taking

Allergies

Medications, Foods, Environmental, Latex and how allergy is manifested

Family History (FH)

Blood relatives: Age, living/deceased, medical problem. Include grandparents, siblings, children

Psychosocial or Social History (SH)

Pt. profile (sexual orientation, marital status, children), Lifestyle risk factors (illicit drug use, smoking/pack year, exercise) , Employment history, Education, Religion – beliefs, Cultural history, Support System, Stressors, Driving

Review of Systems

(ROS)

General statement by the patient (reported symptoms that do not fit one system but often affect overall status)

Skin

Eyes, Ears, Nose Throat/Mouth

Cardiovascular

Respiratory

Gastrointestinal

Reproductive / Genitalia / Genitourinary

Breast/Lymphatics

Musculoskeletal

Neurological

Physical Exam

General/Consitutional

General description of patient including age, gender, nutritional status, habitus, attention to grooming, state of cooperativeness/demeanor, overall picture of wellness/distress

Vital Signs

Temperature, Pulses (apical and radial), Respirations, BP (Ht, Wt, BMI)

Skin

HEENT

Neck

Respiratory

Cardiovascular

Breast/Lymphatics

Abdomen

Female Genitourinary/

GYN

if applicable

Rectal

Musculoskeletal

Including frailty evaluation if applicable

Neurological

( Mental Status, Cranial nerves, Motor, Cerebellum, Motor, Cerebellum, Sensory, Reflexes)

Diagnostic Information

Results of diagnostic testing conducted at the time of the visit OR previously done and being used to support the diagnosis and management plan for the current visit

3-5 differential diagnoses

for each presenting problem

(Population specific wellness exam if no problems identified)

Data in your assessment that supports or rules out this diagnosis

ICD 10 Code

Corresponding Diagnosis

1.

2.

3.

4.

5.

Additional Diagnostic tests needed

Treatments: Pharmacological

Treatments:

Non-Pharmacological

Patient Education

Consultations recommended with

Rationale

Return to Clinic/Follow-Up

Next office visit scheduled, identify the plan for follow-up, note expectations for further treatment.

CPT Code

Corresponding Diagnosis

1.

2.

3.

4.

5.

FNP Student

West Coast University

Patient Name _____________________________________ Date ___________________

Rx

Refill NR 1 2 3 4 5

Signature ____________________________________________________________